A technique to facilitate symmetrical and atraumatic placement of the core suture during flexor tendon repair

A technique to facilitate symmetrical and atraumatic placement of the core suture during flexor tendon repair

Journal of Plastic, Reconstructive & Aesthetic Surgery (2007) 60, 447e449 CASE REPORT A technique to facilitate symmetrical and atraumatic placement...

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Journal of Plastic, Reconstructive & Aesthetic Surgery (2007) 60, 447e449

CASE REPORT

A technique to facilitate symmetrical and atraumatic placement of the core suture during flexor tendon repair S. Akhtar*, F.D. Burke Pulvertaft Hand Center, Derbyshire Royal Infirmary, London Road, Derby DE1 2QY, UK Received 8 January 2006; accepted 25 April 2006

KEYWORDS Tendon repair; Flexor tendon; Technique

Summary We present a technique aiding symmetrical accurate and atraumatic placement of the core suture during tendon repair. This technique facilitates a neat repair and avoids unnecessary contact with the tendon during the insertion of the core suture. ª 2006 Published by Elsevier Ltd on behalf of British Association of Plastic, Reconstructive and Aesthetic Surgeons.

For accurate, placement of the core suture during tendon repair the lacerated tendon end must first be stabilised. To achieve this one must be able to place the tendon under tension. This can only be achieved by handling and consequently further traumatising the lacerated tendon ends. Grasping the tendon end whether at the core or around the circumferential edges, no matter how gently performed inevitably crushes the tendon ends and obscures access for accurate and symmetrical core suture insertion.

* Corresponding author. Tel.: þ44 7795576280. E-mail address: [email protected] (S. Akhtar).

Technique We describe a technique that allows firm stabilisation of the tendon and facilitates placement of the core suture accurately, with symmetry and with minimal trauma to the tendon ends. This technique is derived from the intra-operative finding of frayed or oedematous tendon ends either as a consequence of the initial trauma or as a delayed repair. In such circumstances it is often necessary to debride the ends of the lacerated tendon in order to obtain a good quality repair. This shortening by few millimetres does not generally affect the tension of the repair. The technique involves a two-stage trimming of the cut ends of the tendon. First the tendon end is

1748-6815/$ - see front matter ª 2006 Published by Elsevier Ltd on behalf of British Association of Plastic, Reconstructive and Aesthetic Surgeons. doi:10.1016/j.bjps.2006.04.021

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S. Akhtar, F.D. Burke

Figure 1 (a) Tendon partially incised bilaterally creating a flap of tendon; (b) the flap is grasped with forceps, and the core suture is inserted without handling the remaining tendon; (c) core suture completed; and (d) flap of tendon excised.

partially incised bilaterally with a sharp knife, 1e2 mm from the cut surface (or further back, if this is required to get to good quality tissue). The trimming should be restricted to one-third of the tendon diameter on either side, leaving one-third of the tendon intact at the centre (Fig. 1a). This leaves two flaps of tissue laterally attached to the rest of the tendon by a central bridge of tissue. The flaps can then be folded back together or individually grasped with dissecting or artery forceps allowing excellent control of the tendon to facilitate tendon repair (Fig. 1b). As only one-third of the cross-sectional area of the tendon end is available on either side, the core suture can be placed relatively symmetrically and without difficulty in a well-stabilised tendon (Fig. 1b and Fig. 2). After placement of the core suture (Fig. 1c), the trimming of the tendon end is completed centrally and the flap of tendon is discarded (Fig. 1d). This ensures that although having been handled with forceps, one has not traumatised the tendon ends being approximated. A further core suture can now be placed in the centre of the tendon to complete a four-strand repair, by using both

Figure 2 Figure showing flap of tendon grasped with dissecting forceps allowing unobstructed access to the cross-sectional area of the tendon end for accurate and atraumatic placement of core suture.

Technique aiding symmetrical and atraumatic placement of the core suture

Figure 3

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(a, b) Alternate methods for inserting four-strand modified Kessler core suture.

threads of the previous suture which when placed under tension, allow stabilisation of the tendon (or alternatively, if there is enough space insert the second core before the tendon flap is excised) (Fig. 3a). For a six-strand repair one would insert one core suture into each of the freshly exposed tendon surfaces (Fig. 3b), complete the tendon flap excision and apply the central core suture as previously described. The quantity of tendon used to create the flaps in both Figs. 1 and 3 has been exaggerated to aid the illustration of the technique.

Discussion To obtain good results following tendon repair one must adhere to the following technical principles:  Minimise further trauma to the tendon during repair in order to minimise adhesion formation.1  Accurate placement of the core suture will minimise damage to the intrinsic blood supply of the tendon.2  Symmetrical placement of the core suture is necessary to evenly distribute forces across a tendon repair and consequently stronger tendon repair. Kleinert and Smith3 suggested that, to minimise tendon trauma during repair, only the severed ends of the tendon are handled. In some circumstances the severed tendon ends are found to be damaged from the initial trauma and require debridement to allow for a smooth repair; the surgeon can exploit this circumstance to his or her advantage by

employing the technique we describe and allow for tendon repair without handling the ends of the tendons involved in the repair. The technique also allows for good tendon stabilisation and so the core suture can be placed accurately without fear of damaging the predominately dorsally located blood supply. A variety of techniques have been described to improve the ease of flexor tendon repair and this technique is a modification of the technique described by Majumder et al.4e7 We would not advocate that the technique we describe be used in all tendon repair procedures; however, we feel it is a useful addition to any hand surgeons’ repertoire.

References 1. Bunnell S. Repair of tendons in the fingers and description of two new instruments. Surg Gynecol Obstet 1918;26: 103e10. 2. Tsuge K, Ikuta Y, Matsuishi Y. Intratendinous tendon suture in the hand: a new technique. Hand 1975;7:250e5. 3. Kleinert HE, Smith DJ. Primary and secondary repairs of flexor and extensor tendon injuries. In: Jupiter JB, editor. 4th ed., Hand surgery Baltimore: Williams and Wilkins; 1991. p. 247. 4. Wright II PE. Flexor and extensor tendon injuries. In: Canale ST, editor. 9th ed., Campbell’s operative orthopaedics St Louis: Mosby; 1998. p. 3325. 5. Watts AM, Heras-Palou C. No more frayed ends e a technique for trimming the uneven ends of ruptured flexor tendons prior to repair. J Hand Surg [Br] 2003;28(3): 231e2. 6. Majumder S, Hough M, Haeney J, et al. A safe technique to secure flexor tendons during repair. Plast Reconstr Surg 2003;12(4):119. 7. Lin GT. The holding technique for flexor tendon repair. Plast Reconstr Surg 1988;81:965e6.